In specialty medicine, histories start before the appointment

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When clients come into the clinic, they want to give you as much information as possible because they’ve come to you for answers. As a technician, it's important to be a sympathetic ear, but also to get the facts needed to help the doctor come up with a plan. I’ve been a veterinary technician for 20 years and worked in cardiology, internal medicine, oncology, and orthopedics for about 15 of those years. I’ve learned what works and what doesn’t when it comes to history taking and it starts before you enter the exam room.

The first step is making sure you have all the previous records from the client’s local veterinarian and any other specialty or emergency hospitals they’ve been to. Making a timeline of events is helpful when you have multiple sets of records, but the most important thing to look for is when did the problem begin. That gives you a good place to start your record reviewing. Although it’s important to know all the past pertinent history, you don’t need to include every detail, such as an ACL repair that happened 5 years ago when the pet is presenting to you for symptoms of Cushing’s disease.

The next items to look for are diagnostics that have already been performed and medications that have been prescribed. It’s best to know when these diagnostics took place and make sure the results of those tests are available to the doctor. It’s helpful to see what was already prescribed so you can confirm the medication with the client during the appointment. Keeping track of multiple medications can be overwhelming to clients so it’s helpful to have a list ready that you can confirm with them instead of the client coming up with a list on the spot.

For a client’s history, it is best to keep all of it in chronological order. Depending on the doctor, start from what’s currently going on and work backwards, or start at the beginning and move forward in time. Always use proper medication names, routes, times of administration, and use proper medical terminology. I like to write a history based on the records we’ve received before the appointment and then fill in the details with what the client tells me during their appointment. When it comes to specialty medicine, you need to know the story before entering the room because it’s hard to keep the client on topic if you don’t.

Once it’s time for the appointment to start, keep in mind that you need to be in charge of the conversation. Of course, you want to be kind and understanding, but you have a limited amount of time to get the information you need. Keeping a client on topic is hard when they care so much about their pet and want to share every detail about them. If the conversation train has gone off the rails, I find it helpful to say something like, “Let’s talk more about Olivia’s appetite changes” or “Can I interrupt you to talk more about Elliot’s cough? Have any medications helped so far?” to snap clients back to the present to continue telling me about the current issue. When discussing symptoms, you want to find out the frequency, duration, and severity. You also want to know what the clients tried on their own, like food or routine changes that might not have made it into medical records.

At the end of my time in the appointment, I let clients know what to expect next in terms of diagnostics and ask them what their goal is for the appointment. Depending on the department, it might not be obvious why the clients are there, especially in departments like internal medicine. It’s good to know what the client’s expectations are before the doctor enters the room. Once you have verbally given the veterinarian your history and answered any questions they have, it’s good practice to proofread the history you have written in the medical records. Make sure it makes sense and there are no spelling or grammatical errors. Days in any clinic are busy and you may forget details after the appointment. Make sure you have all the necessary information in the records before you move on to another task.

Writing a history takes effort before, during, and after the appointment. The technician is the strongest link between the client and doctor. If you put together a thorough history, you can feel proud that you helped your client get the answers they need to help their pet.